Part B Insider (Multispecialty) Coding Alert

When a physician upcodes or downcodes an evaluation and management claim, most of the time it's only by one level. That should be considered a matter of professional judgment, because even Centers for Medicare & Medicaid Services officials can't always agree on the correct E/M level for a particular visit, says a spokesperson from the American Medical Association.

In its most recent House of Delegates meeting, the AMA urged CMS to give physicians relief from fraud and abuse witch-hunts. The AMA suggested that if a physician is only one level off the correct E/M level, this shouldn't count as fraud and abuse.

The AMA resolved to work with the HHS Office of Inspector General to clarify the criteria that would trigger a Medicare audit, and establish new rules spelling out the physician's rights in case of an audit. Also, the Delegates resolved that the AMA should "advocate forcefully" for CMS and the OIG to end all random review of E/M services and to consult with independent peer reviewers before doing any post-payment audits of E/M services.

Finally, the AMA will seek legislation or regulations that will make clear that E/M coding is imprecise by nature and audits should give credit for downcoding along with upcoding.